The year 2011 is starting out rather promisingly, at least from the point of view of science-based medicine. Its beginning coincides with the release of two — count ’em, two! — books taking a skeptical, science-based look at vaccines and, in particular, the anti-vaccine movement. First off the mark is a new book by a man whom the anti-vaccine movement views as the Dark Lord of Vaccination, sitting up in Barad-dûr (apparently the University of Pennsylvania and Children’s Hospital of Philadelphia), a man utterly reviled by anti-vaccine quacks everywhere, Dr. Paul Offit. He has been subjected to considerable bile and harassment due to his simply standing up for the science behind vaccines. The book is entitled, appropriately enough, Deadly Choices: How the Anti-vaccine Movement Threatens Us All. Also being released is a new book by Seth Mnookin entitled The Panic Virus: A True Story of Medicine, Science, and Fear. Mnookin is a contributing editor at Vanity Fair and whose work has appeared in numerous publications. Because I got a copy of Deadly Choices before my copy of The Panic Virus arrived, I decided to review Deadly Choices first; after I’ve managed to read The Panic Virus, I’ll write a review of it as well. Both books are arrows shot at the heart of the pseudoscience and fear at the heart of the vaccine manufactroversy, and it might well be useful to compare and contrast the two once I’ve finished The Panic Virus.

In the meantime, let’s take a look at Deadly Choices, an excellent, well-researched book with which I have relatively few disagreements. It is a followup to Dr. Offit’s last book, Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure, which I reviewed back when it first came out. In contrast to Autism’s False Prophets, which concentrated primarily on the manufactroversy that claims that vaccines are responsible for the “autism epidemic,” Deadly Choices steps back to take a broader look at the anti-vaccine movement. Regular readers of SBM hardly need to be reminded how pervasive and dangerous the modern-day anti-vaccine movement has become. Indeed, it is a frequently discussed theme of this blog, given that the anti-vaccine movement is such a major force among the forces that deny the efficacy of scientific medicine and seek either to replace it with unscientific or pseudoscientific “alternatives” or to “integrate” pseudoscience into science-based medicine. Indeed, anti-vaccine sentiment infuses large swaths of what we refer to as “complementary and alternative medicine” (CAM), be it chiropractic, homeopathy, traditional Chinese medicine, or a wide variety of other modalities and systems.

In examining the modern anti-vaccine movement, Dr. Offit structures his book into three major sections. First, beginning in a chapter entitled The Birth of Fear, Dr. Offit begins with a description of the birth of the modern anti-vaccine movement, which in the U.S. Dr. Offit traces, in large part, to the broadcast of an irresponsible and anecdote-driven news documentary about the diptheria-pertussis-tetanus (DPT) vaccine in 1982, and in the U.K. to a scare about the DPT triggered by a presentation by Dr. John Wilson to the Royal Society of Medicine about horrific complications thought to be due to the pertussis vaccine in the DPT. Next, Dr. Offit goes back into history to describe the development of the anti-vaccine movement in the 1800s in England and notes parallels with the modern day anti-vaccine movement. Finally, the story shifts back to today, where he describes the situation now, how demands for vaccines turned into fear of vaccines, and what we might do about it.

1982: The birth of fear

Dr. Offit’s telling of the tale of how a documentary written and produced by Lea Thompson entitled DPT: Vaccine Roulette, which first aired on a local NBC affiliate in Washington DC on April 19, 1982, and then ultimately was aired nationally on The Today Show. This irresponsible bit of muck-raking used the very same technique that anti-vaccine activists have used since the very beginning. Indeed, a passage from Deadly Choices give you a flavor of how this documentary presented anecdotes designed to support the documentary’s thesis that the whole cell pertussis vaccine in use at the time resulted in brain injury:

POLLY GAUGERT, AGE 7, REACTION: FEVER, UNCONTROLLED SEIZURES, BRAIN DAMAGE. “I said that maybe she should not have had this shot because it seems to me that she was not quite herself,” recalled Polly’s mother. “And [the doctor] checked her all over and he said, ‘She looks okay to me,’ and then he gave her the shot. And the next morning when I was feeding her she went into a grand mal seizure…I didn’t know what was happening. I thought she was dying in my arms.”

Note how it appears that there was something wrong with Polly before she was given her vaccine, but this anecdote was presented as though her seizures were definitely due to the DPT. It’s the classic fallacy of post hoc ergo propter hoc, namely the fallacy of assuming that because vaccination occurred before Polly had seizures then the vaccine must have caused the seizures. Sometimes a temporal relationship implies causation, often it does not. Multiple other anecdotes were presented in support of a story that claimed that physicians knew about the problems with the DPT and had tried to cover it up. Highly dubious physicians like Dr. Robert Mendelsohn, whom I first encountered when I was in medical school and a friend gave me a copy of Mendelsohn’s book, Confessions of a Medical Heretic, which I remember as primarily a jeremiad against modern medicine that mixed reasonable criticisms of how modern medicine operated with rants that represented surgeons as bloodthirsty butchers who didn’t care if operations were necessary or not but were greed-heads who just wanted to cut. He was particularly harsh on obstetricians and gynecologists, whom he characterized as sacrificing women on the altar of surgery during childbirth. Not surprisingly, it turns out that Dr. Mendelsohn is anti-vaccine to the core, stating baldly that “while the myriad short-term hazards of most immunizations are known (but rarely explained), no one knows the long term consequences of injecting foreign proteins into the body of your child” and that “there is growing suspicion that immunization against relatively harm-less childhood diseases may be responsible for the dramatic increase in auto-immune diseases since mass inoculations were introduced.”

This birth of fear didn’t happen just because of one bad documentary. In describing how the anti-vaccine movement was reborn in the U.S. in the 1980s, Dr. Offit uses a slightly less explicit version of a technique he used in Autism’s False Prophets, wherein he describes the evidence for a link between the whole cell pertussis vaccine and neurological damage. In Autism’s False Prophets, Dr. Offit listed a panoply of studies that appeared to indict mercury in the thimerosal preservative used in vaccines in the U.S. before 2001 as a cause or contributor to autism in such a way that evidence for a link seemed persuasive, only to be followed by a chapter deconstructing that evidence and showing why it was not scientifically sound or convincing at all. For instance, he describes a very influential study that was released in the early 1980s by Dr. David Miller, a professor of community medicine at the Central Middlesex Hospital in London, that seemed to show a very strong link between DPT vaccination and seizures and other neurological problems. I must admit, at that point, early in the book, the evidence sounded convincing to me. Dr. Offit then followed up the description of this study with a listing of studies that failed to find any link between DPT and neurological injury or dysfunction, as well as a highly revealing description of how Miller, in bending over backwards to deflect any criticism that he was downplaying a potential link between his DPT and neurological injury, actually had inadvertently rigged his study to vastly overstate the rate of neurological injury and set it up to find massive false positives. This was more subtly done in Deadly Choices than in Autism’s False Prophets, and this is to the good, because it gives insight how, in the 15-year period during which followup studies to Miller’s were being done, there was real doubt over whether DPT caused neurological injury in some children.

It turns out, however, that the reason DPT: Vaccine Roulette takes such a prominent place in Deadly Choices is because it galvanized people who were either anti-vaccine or who were just suspicious of vaccines, among them a player whom we’ve discussed on multiple times before, namely Barbara Loe Fisher, co-founder and current president of the anti-vaccine group the National Vaccine Information Center. I’ve discussed Barbara Loe Fisher and the NVIC on multiple occasions before. Before the rise of Generation Rescue and Jenny McCarthy, Fisher’s group was the undisputed champion of anti-vaccine movements. Charismatic and media-savvy, Fisher became the go-to woman for any story about vaccines. She even managed to infiltrate herself onto the Vaccines and Related Biological Products Advisory Committee of the Food and Drug Administration, a position she held from 1999 to 2003. (Today, she sits on the Vaccine Safety Writing Group, National Vaccine Advisory Committee, U.S. Department of Health & Human Services.) Yes, Barbara Loe Fisher sits on the committee that decides which vaccines will be recommended for children. Fisher is a bit of an odd bird in that she played a major role in promoting and passing the legislation that formed the National Vaccine Injury Compensation Program, which, as Dr. Offit describes, arguably saved the vaccine program in the U.S. Before the VICP, vaccine manufacturers were abandoning vaccines in droves due to a tsunami of lawsuits. After the VICP, the federal government assumed first liability for vaccine injuries and created a relatively low threshold standard for compensating health problems attributed to vaccines. Fortunately, as Offit describes, its standards aren’t completely uncritical, as is best demonstrated by the failure of the Autism Omnibus. (I’ve written about the Autism Omnibus in detail.)

Perhaps the most devastating argument Dr. Offit uses against Barbara Loe Fisher and the anti-vaccine movement in general is to dismantle their claim that they are not “anti-vaccine,” but rather pro-safe vaccine. Barbara Loe Fisher was on an important FDA advisory committee for nearly five years and has been a prominent presence in the press whenever stories about vaccines occur since 1982. During that time, Dr. Offit observes, she has never spoken out in favor of a single new vaccine. Not one. The haemophilus influenza type B (Hib) vaccine, a vaccine that has saved thousands of lives over the last two decades since it was introduced by preventing huge numbers of cases of Hib meningitis and other complications, reducing the incidence of a disease that was, when I was in medical school, one of the most feared scourges of young children? She opposed it. Hepatitis B vaccine? Fisher opposed it, promoting dubious science, since refuted, that the vaccine caused multiple sclerosis. After joining the Vaccines and Related Biological Products Advisory Committee, Fisher’s very first vote was to oppose the introduction of the pneumococcal vaccine, which was ultimately approved by a vote of 11-1. She also, not surprisingly, opposed the introduction of the HPV vaccine. All the while, Fisher wrote about how she thought vaccines caused immune problems, neurological problems, and all manner of chronic health issues while decrying the concept of herd immunity and claiming that “natural” infections are better than vaccination. Dr. Offit then contrasts Fisher with a man named John Salomone, who identified a real problem with U.S. vaccination policy (the use of the oral polio vaccination, which, because it consisted of a weakened version of the polio virus, could on rare occasions reconstitute itself into a fully functional polio virus and thus cause polio) and advocated for a change to the inactivated polio vaccine. While Fisher did little but rail against doctors, label all vaccines as dangerous, equate physicians who opposed her to Nazi doctors, and try her best to prevent any new vaccines from being approved, Salomone brought about real improvement in how we vaccinate.

Offit is correct that real vaccine safety advocates work for changes that will bring about real improvements in vaccine safety. Anti-vaccine advocates work to label all vaccines as risky and to prevent as much vaccination as possible.

History

Noting that the “past is prologue” in a chapter, Dr. Offit next moves on to a discussion of the history of the anti-vaccine movement. While I think I understand why he chose to present the issue the way he did, I was disappointed in that he in essence traced the development of the first anti-vaccine movement to the middle of the 19th century in England, when in fact anti-vaccine movements sprung up far earlier. To read Offit in this respect, I got little sense of how the anti-vaccine movement of the mid-19th century was a direct descendent of the anti-variolation movements that had sprung up a century earlier. Arthur Allen included in his book Vaccine: The Controversial Story of Medicine’s Greatest Lifesaver, a particularly good discussion of how anti-variolation activism ran rampant in Boston in 1721. There and then, Cotton Mather and a physician named Zabdiel Boylston were pilloried in the press and popular opinion for their promotion of variolation, a much less safe precursor to Edward Jenner’s cowpox vaccination in which smallpox puss was inoculated into the skin with a needle, resulting in a mild case of smallpox that would ultimately confer immunity. Ironically, Benjamin Franklin, who was 16 at the time and would later become a champion of variolation in Philadelphia, was part of the press that attacked Mather and Boylston.

Be that as it may, I’m sure the reason that Dr. Offit chose to place the origin of the anti-vaccine movement in the 1800s was because it is a cautionary tale of how government policy can inadvertently backfire. Although it’s not new news, in the context of tracing the origins of the modern anti-vaccine movement Dr. Offit convincingly demonstrates that one of the consequences of the Vaccination Act of 1853, which made vaccination against smallpox mandatory for infants. In 1867, 1871, and 1873, followup acts were passed that made vaccination compulsory. During this same time period, resistance to vaccination increased, with rallies, protests, and increasing civil disobedience.

In contrast, Dr. Offit convincingly argues that mandatory vaccination, which is what we have in the U.S., is far more effective. Mandatory, in contrast to compulsory vaccination, requires vaccination as a precondition for using certain public services, specifically the public schools. The message is that you don’t have to vaccinate you kids if you really don’t want to. No one from the government is going to come around and fine you or force you to vaccinate them, as what happened in England in the middle and latter parts of the 19th century. However, if you don’t vaccinate there’s a price to pay. If you don’t vaccinate, your kids can’t go to public school because they would then have the potential to bring disease there and serve as the nidus for epidemics. Since that policy was instituted, vaccination rates in the U.S. has skyrocketed. In contrast, Dr. Offit points out that the proliferation of religious and philosophical exemptions is threatening our high levels of vaccination. He also points out (and I agree) that these exemptions are unlikely to be rolled back, using as his justification the argument that the law has a hard time touching faith healers and parents who choose prayer instead of effective medicine for their children, even when children die as a result. Unfortunately, I have a hard time arguing with Dr. Offit here. I also have a fairly hard time arguing too strongly against religious exemptions, given the primacy of the First Amendment. Philosophical exemptions, on the other hand, should be eliminated or made much harder to obtain.

Perhaps the most persuasive part of this section is a description of the parallels between the anti-vaccine movement of the mid- to late 1800s and the anti-vaccine movement of today, which include the recurring themes and tactics of:

Doctors are evil

Public rallies

Paranoia

False claims of vaccine harm

The claim that vaccines are somehow “unnatural”

Rejection of the germ theory of infectious disease

The lure of alternative medicine

Fear of Science

The argument that vaccines are an act against God

Mass marketing

There are also some interesting contrasts, too. For instance, in the 1800s, anti-vaccine activism tended to occur among the poor and the working class, mainly because compulsory vaccination laws were explicitly targeted at the poor. In contrast, today the anti-vaccine movement is primarily a product of educated, affluent people living in highly affluent neighborhoods. Even so, the sameness of the arguments used 150 years ago with those used today is striking.

What to do?

Dr. Offit finishes with a discussion of the state of the anti-vaccine movement now. Included are deservedly unflattering portrayals of the usual suspects, including Jenny McCarthy and Jim Carrey, J.B. Handley, Bill Maher, and the organizations involved in promoting anti-vaccine views, such as Generation Rescue. He also points out how a new element has entered the anti-vaccine repertoire, namely personal intimidation, an art at which J.B. Handley has demonstrated his skill through his misogynistic attacks on Amy Wallace and his tendency to try to threaten and bully journalists who have the temerity to criticize him or the anti-vaccine movement. (I myself have fallen victim to this sort of intimidation.)

Ironically enough, this sort of personal opprobrium against Dr. Offit has continued, as the anti-vaccine blog Age of Autism, which is in essence Generation Rescue’s propaganda arm, gave Dr. Offit an “award”: Age of Autism Awards 2010: Dr. Paul Offit, Denialist of the Decade. This appears to be a relatively new talking point among the anti-vaccine set. Stung by being lumped in with evolution denialists, anthropogenic global warming denialists, not to mention quacks and “alternative medicine” advocates (denialists of science-based medicine), apparently anti-vaccine activists have decided that they’ll try to appropriate the term “denialist” by referring to those who refute their pseudoscientific nonsense as “vaccine safety denialists” or some similar term.

Perhaps the most useful chapter in the entire book is Dr. Offit’s chapter analyzing the claims of Dr. Bob Sears, whose “alternate vaccine schedule” has tortured pediatricians everywhere, with its “spreading out” of vaccines and Sears’ recommendation to exclude certain vaccines as not sufficiently safe. Dr. Offit has taken on Dr. Sears before, as has our very own Dr. John Snyder. In any case, Dr Offit makes the convincing case that “Dr. Bob,” if not a full-fledged anti-vaccinationist, is at the very least an anti-vaccine sympathizer, given that he regurgitates these anti-vaccine talking points, all of which are exaggerated or false:

As an added bonus, Dr. Offit spends a bit of time taking on Dr. Mehmet Oz’s misstatements about vaccines and a lot more time indulging in a richly deserved skewering of Dr. Bernadine Healy, former director of the NIH, who was named Age of Autism’s Person of the Year in 2008 and has put herself back in the news by “questioning” the current vaccine schedule using talking points cribbed from the anti-vaccine movement.

In the final chapter, Dr. Offit correctly identifies the problem as a lack of trust between parents and health officials, pointing out that it’s easy to come up with conspiracy theories about, for example, pharmaceutical companies because they are to most people faceless institutions with profits as their primary motive. To try to combat this impression, he introduces us to scientists from Merck who work on vaccines, their dedication, and their passion. That’s good. What’s not so good is that Dr. Offit fails to acknowledge adequately that there is good reason why many people distrust pharmaceutical companies. We’ve written about some of those very reasons myself, including pharma ghostwriting, seeding trials, and conflicts of interest. Let’s just put it this way. I like Dr. Offit, and I wanted to like this book, but even to me this argument fell flat because it more or less dismissed the contention that not all distrust of pharmaceutical companies is unreasonable or overblown. Far better is his pointing out that parents whose children have been injured or killed by vaccine-preventable diseases represent an underutilized resource for countering the misinformation of the anti-vaccine movement.

Finally, one other problem with the book that I had is that Andrew Wakefield is only mentioned relatively briefly when arguably he should have a whole chapter devoted to him, given his extreme prominence in the anti-vaccine movement and how much damage his shoddy, litigation-funded science did to herd immunity in the U.K. True, Wakefield featured prominently in Autism’s False Prophets, but that does not justify giving him such short shrift in Deadly Choices. He is simply too seminal a figure in the anti-vaccine movement of the last 12 years. As far as I’m concerned, it can’t be repeated enough times just how badly Wakefield violated medical ethics and utterly and thoroughly discredited his work is.

Those complaints aside, though, Deadly Choices is a timely and important book that serves to counter the misinformation promulgated by the anti-vaccine movement. In particular, Dr. Offit writes:

…far from being unwilling to study whether parents’ concerns about mercury were real, public health officials and academic investigators had performed many studies to determine whether mercury in vaccines caused autism or other problems. It didn’t. And those studies cost tens of millions of dollars to perform.

The same statement could apply to all the studies of the MMR vaccine and autism as well. In fact, the same could be said of all the research inspired by fears stoked by the anti-vaccine movement. More’s the pity, and Dr. Offit’s book reminds us just how much time, effort, and money have been wasted chasing fanciful hypotheses of vaccine injury, thanks to the anti-vaccine movement. Relatively minor deficiencies aside, it’s a primer on the anti-vaccine movement that I heartily recommend to SBM readers.